Adult Encounter Form Name* First Last Date of Birth Date Format: MM slash DD slash YYYY NicknameGenderRaceSocial Security #Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneE-Mail* Preferred LanguageOccupationHobbiesPrimary Care DoctorCityMonth of last examVISUAL & OCULAR HISTORYDo you wear glasses, and what type?I do not wear glassesI previously wore glassesDistance glassesReading glassesComputer glassesProgressivesBifocalsDo you wear contact lenses?YesNoI would like to learn about starting in contactsBrandRight PowerLeft PowerDo you currently experience any of the following? (please check all that apply) Blurry distance vision Blurry near vision Difficulty seeing at night Double vision Eyestrain or tired eyes Dry eyes (sandy/gritty feeling) Itchy eyes (need to rub) Watery eyes Eyes are often red Crusty or sticky eyelids/lashes Flashing lights in vision Floating spots in vision Any history of the following? (please check all that apply) Cataracts Dry eye disease Dry eye disease Glaucoma Macular degeneration Retinal hole or detachment Amblyopia (lazy eye) Strabismus (eye turn) Frequent sties (eyelid bumps) Sudden loss/change of vision Head, facial or ocular trauma Refractive surgery (LASIK/PRK) Ocular surgery (cataract, strabismus, etc.) Other ocular disease please describe what and whenplease describe what and whenplease describe what and whenplease describe what and whenplease describe what and whenplease describe what and whenDo you take any eye drops or artificial tears? If yes, please listMEDICAL HISTORYList all of your prior and current MEDICAL CONDITIONSList all current MEDICATIONS, including vitamins and supplementsList any ALLERGIES to medications, foods, or materials No known drug allergiesREVIEW OF SYSTEMSDo you currently have, or have you ever had, any of the following problems or conditions? (check all that apply)Constitutional Fever, Weight Loss/Gain Obesity Cardiovascular Heart Disease High Blood Pressure High Cholesterol Vascular Disease Respiratory Asthma Chronic Bronchitis Emphysema Sleep Apnea Ear/Nose/Mouth/Throat Dry Mouth/Throat Seasonal Allergies Sinus Congestion Runny Nose Chronic Cough Endocrine Diabetes Mellitus Thyroid or Gland Disease Gastrointestinal Constipation Crohn’s Disease Diarrhea Ulcer / Reflux Genitourinary Bladder/Genital/Kidney Musculoskeletal Rheumatoid Arthritis Osteoarthritis Muscle Pain Joint Pain Integumentary (Skin) Skin Cancer Rosacea Herpes Zoster / Shingles Neurological Headaches Migraines Multiple Sclerosis Loss of Memory Seizures Psychiatric Anxiety / Depression Lymphatic / Hematologic Anemia Bleeding Problems Allergic / Immunologic Seasonal Allergies Eczema Hives Lupus Erythematosis Organ Transplant Lyme or Infectious Disease Use this space to elaborate on any conditions specified aboveSOCIAL HISTORYSmokers are at higher risk for macular disease. Do you smoke tobacco?NeverFormerlyCurrently What type?For how long?Amount?pack(s) /Do you drink alcohol?No or rarelySocially or occasionallyMost daysEvery dayDo you use marijuana or any illegal drugs?YesNoI useHave you ever been exposed to or infected with Gonorrhea Syphilis Hepatitis HIV FAMILY OCULAR HISTORYPlease indicate the relation of any family member with history of the following (ex: paternal-grandmother)GlaucomaMacular DegenerationStrabismus/Eye TurnAmblyopia/Lazy EyeCataractsBlindnessOther Ocular DiseaseFAMILY MEDICAL HISTORYPlease indicate the relation of any family member with history of the following (ex: paternal-grandmother)Heart DiseaseHigh Blood PressureHigh CholesterolDiabetesThyroid DiseaseCancerBlood DisordersMultiple SclerosisOther DiseaseI state that the above is true to the best of my knowledge.Patient’s SignatureDate Date Format: MM slash DD slash YYYY
